Drug Classes to Deprescribe in Older Persons with HIV in Presence of Certain Conditions

Deprescribing should aim to reduce pill burden, drug toxicities, falls, hospital admission, mortality and improve Health related Quality of Life.


Acetylcholinesterase inhibitors

e.g, donepezil, rivastigmine

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
History of persistent bradycardia
(< 60 beats/min), heart block, or recurrent syncope or coadministration of beta-blocker, digoxin, diltiazem, verapamil		 Increase the risk of cardiac conduction failure, syncope and injury Taper gradually, consider halving the dose every 4 weeks


Antipsychotics

e.g., haloperidol, lurasidone, paliperidone, perphenazine

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Parkinson Severe extra-pyramidal symptom quetiapine, clozapine


Aspirin

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Low cardiovascular risk and/or advanced age and/or high risk of gastrointestinal bleeding (e.g., concurrent use of NSAIDs, SSRIs, corticosteroids) and/or prior gastrointestinal disease and/or coadministration of a second antiplatelet or anticoagulant (continued beyond the recommended duration) Risk of bleeding No need to taper


Biphosphonates

e.g., alendronate, ibandronate, risedronate, zoledronate

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Low risk of fracture or history of 5 years of continuous treatment with a bisphosphonate Biphosphonates keep showing a benefit in non-vertebral fractures in the 5 years after an initial treatment particularly if the T score is above -2.5. Prolonged use increases the risk of osteonecrosis of the jaw, hypocalcemia and/or severe vitamin D deficiency.

No need to taper


Opioids

e.g, codeine, fentanyl, morphine, oxycodone, tramadol

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Chronic non-cancer pain Tolerance to analgesic effect of opioids with long-term use. Associated with adverse psychological effects, higher risk of death from drug overdose with opioids. Multidisciplinary pain management program. Written and verbal instructions should be provided to patients and families to educate about the tapering protocol that will minimize the withdrawal symptoms


Proton pump inhibitors (PPIs)

e.g, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Uncomplicated peptic ulcer disease Long-term use is linked with increased risk of fracture, enteric infections, mineral deficiencies Use low dose of PPI -> if symptoms well controlled -> use PPI on demand -> if symptoms well controlled -> stop PPI


Selective serotonin re-uptake inhibitors (SSRIs)

e.g., citalopram, fluoxetine, paroxetine, sertraline

Conditions for which deprescribing should be considered Problems caused by drug class Alternatives or information on how to stop drug
Current or recent significant hyponatremia (i.e. serum Na+ <130 mmol/L) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) and aggravation hyponatremia agomelatine, bupropion, mianserin, trazodone. Note: tricyclic antidepressants should be avoided as associated with a higher risk of adverse effects (e.g., life-threatening arrhythmias and heart block)